Pathology/Lab Coding Alert

Question: We're getting denials when our lab performs a lipid panel and an LDL cholesterol. How can we get paid for both services?

Texas Subscriber

Answer: Physicians often order both a lipid panel (80061, Lipid panel) and a low-density lipoprotein cholesterol (83721, Lipoprotein, direct measurement; LDL cholesterol) because both tests provide important information about the patient's lipid profile. Although LDL measurement is not included in the lipid panel, labs can, and often do, calculate the LDL value from the results of the lipid panel tests. That's why National Correct Coding Initiative edits bundle 83721 with 80061, and that's probably why you're getting denials.

But labs can't always calculate the LDL - if the triglyceride reading is too high (e.g., over 400), labs cannot calculate the LDL and must measure that component in a separate test. If the lab performs a valid calculated LDL, you should not bill separately for the LDL cholesterol measurement.

Sometimes Medicare will pay for 83721 with 80061. CMS indicates that "direct measurement of LDL cholesterol (83721) or lipid panel (80061) may be reasonable and necessary if the triglyceride level is too high to permit calculation of the LDL cholesterol."

If the patient's triglyceride result is too high and your lab performs a separate LDL direct measurement, you are entitled to payment for both 80061 and 83721. To ensure payment, append modifier -59 (Distinct procedural service) to 83721 so your claim will bypass Medicare's bundling edit.

Medicare does not clearly define the exact triglyceride level above which providers can bill the LDL measurement separately. Because Medicare's instructions are unclear, your lab should determine a specific triglyceride level above which it considers the LDL direct measurement necessary, and be sure to consistently abide by this standard.